Provider Demographics
NPI:1407016199
Name:KIMBROUGH, ADDIE DELOIS
Entity Type:Individual
Prefix:MS
First Name:ADDIE
Middle Name:DELOIS
Last Name:KIMBROUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1298 HARTFORD TPKE
Mailing Address - Street 2:10D
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2175
Mailing Address - Country:US
Mailing Address - Phone:203-287-5439
Mailing Address - Fax:203-287-8793
Practice Address - Street 1:1298 HARTFORD TPKE
Practice Address - Street 2:10D
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2175
Practice Address - Country:US
Practice Address - Phone:203-287-5439
Practice Address - Fax:203-287-8793
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTHCA.0000233372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion